- California County Behavioral Health Directors Association
- Division of Substance Abuse Prevention and Control, Los Angeles County Department of Public Health
- California Consortium of Addiction Programs and Professionals (CCAPP)
California's SUD treatment services had developed over time as a siloed system of care, isolated from the rest of the health care system, with its own practice philosophy, regulatory structure, and funding streams. Although the limited Medicaid coverage and reimbursement rates were regulated by the state, counties had the authority to organize their own service delivery systems. Throughout the past two decades, however, the state has been gradually integrating SUD treatment services with its health care system, and these activities accelerated in response to recent federal policy changes. The MHPAEA and the Affordable Care Act were key milestones in this integration process, followed by the approval of an amendment to the state's waiver authorized by Section 1115 of the Social Security Act. With the approval of this amendment in 2015, California became the first state to initiate a Section 1115 waiver demonstration specifically designed to transform its SUD service delivery system.
The state's Drug Medi-Cal Organized Delivery System (DMC-ODS) pilot program is the reform mechanism through which the waiver is being implemented. DMC-ODS uses Medicaid funds to expand coverage for SUD services, structured around the American Society of Addiction Medicine (ASAM) criteria, including a waiver of the restriction for treating SUD patients in institutions for mental diseases (the IMD exclusion). Participation in the DMC-ODS is voluntary for the state's 58 counties, in keeping with the relative autonomy that California counties have traditionally had in managing their publicly funded health systems. Counties that choose to opt-in are required to submit an implementation plan for approval by the state's Medicaid authority (Medi-Cal). As of June 2018, 40 counties had submitted plans, 11 had started implementing the DMC-ODS, and approximately 80% of the state's population resided in an "opt-in" county.
The DMC-ODS gives counties some flexibility to set reimbursement rates that align with county-specific cost of living parameters. Although the state will continue to set reimbursement rates, opt-in counties may propose higher or lower rates for all SUD services except those provided under the Narcotic Treatment Program that regulates medication assisted treatment. Counties are required to justify their proposed rates, if different from the statewide rates, and there is typically a negotiation process before state approval is obtained for implementing the rates with funding from the demonstration. This fiscal flexibility gives counties the ability to negotiate rates that align with county-specific cost of living parameters. Non-ODS counties continue to use reimbursement rates set by the state. Under the waiver, the DMC-ODS functions as the health plan for behavioral health for each of the opt-in counties and the counties operate as MCOs contracting with the state to create and maintain their own provider networks within the county. In sum, in addition to broadening the range of reimbursable SUD services and increasing reimbursement rates for existing services, DMC-ODS has enhanced counties' autonomy in the use of public funds for behavioral health services; this, in turn, has increased the variation in health systems across counties. Private health plans in opt-in counties are required to establish memoranda of understanding with the county and to abide by their county's DMC-ODS rules
Given the differences in DMC-ODS implementation across counties, this case study selected a single DMC-ODS county to investigate provider experiences under the waiver. We selected Los Angeles County because of its large population; with more than 10.2 million residents, LA County is the most populous in California and has almost three times the population of California's next largest county (San Diego, population 3.3 million).
Barriers to Substance Use Disorder Workforce Development
California has historically experienced severe SUD provider shortages, especially in rural areas. According to the senior director of government affairs at the California Consortium of Addiction Programs and Professionals (CCAPP), the typical practitioner is over 40; and prior to the waiver, there were few incentives for entry into the field to replace retiring practitioners. The key barriers to developing this workforce were:
Lack of integration with the health care system.
Low salaries and insufficient reimbursement rates.
Low skill requirements.
Absence of a state-regulated licensure process for addiction counselors.
Lack of pathways to insurance reimbursement as an independent practitioner.
As mentioned in the previous section, the SUD field in California has been isolated from the rest of the health care system and developed within an altogether different landscape than the other counseling professions. This isolation had several implications for the workforce. First, SUD treatment professionals were paid considerably less than other health professionals. The range of services covered by public funds varied widely across the state, depending on each county's resources such as discretionary grants and county general funds. A related factor is that in several counties, the safety net for SUD treatment is reserved for the criminal justice-involved population and depended on the availability of funds from sources other than Medi-Cal. This has been an impediment to system integration and to the development of a professional identity for SUD practitioners as health care professionals. For example, the Los Angeles county administrator pointed out:
"Our providers are more experienced interacting with courts, attorneys, the sheriff, and the Department of Child and Family Services than they would be with the primary care provider or with a dentist."
These factors constituted disincentives for new graduates with counseling degrees to specialize in addiction. The DMS-ODS Transformation brings the criminal justice-involved populations into the Medi-Cal safety net, thus weakening the link between SUD treatment and the criminal justice system
Related to the above factors, skill requirements for SUD practice have been, and continue to be substantially lower compared to other counseling services. The state has no prerequisites for practice in the field other than registering with one of the two state-accredited certification organizations, the California Association of DUI Treatment Programs (CADTP) that certifies Alcohol and Other Drug Abuse Counselors or the CCAPP that offers certification in three SUD counselor levels as well as two levels of SUD counseling license. None of these credentials, however, are required by the state for providing SUD services. There are no state-regulated training requirements for becoming a registrant, although the certification boards have reached a consensus decision to require a standard 9-hour orientation and ethics training for registration. Registrants have 5 years to work towards certification, during which time they are authorized by the state to provide counseling services. The CCAPP director we interviewed pointed out that most SUD practitioners use the 5 years as registrant to gain professional experience and work toward higher counseling credentials but given the low salaries of certified SUD counselors, most of them choose to pursue certification in a counseling field other than SUD. These factors combine to create an SUD workforce comprised mostly of registrants at the entry-level and higher-level counselors certified in non-SUD specialties at higher levels. It is worth noting here that the registrant position (Registered Alcohol and Drug Technician) comprises the lowest rung of the model career ladder for SUD professionals developed by SAMHSA.
To get Medicaid reimbursement, practitioners need to work in certified provider organizations and there are very few commercial plans willing to reimburse independent SUD practitioners.
Our informant indicated that under the terms of the state's facility licensure, 30% of a provider organization's staff need to be certified counselors (not necessarily in the addiction field) with at least 155 hours of education. She pointed out that these are low education and staff certification standards. The certification boards in the state, through a consensus decision, now require 315 hours of education for certification as an addiction counselor. However, this has not increased the overall skill level of SUD practitioners by much: Given the low salaries for certified SUD counselors and the ability to work for 5 years as a registrant, early-career It practitioners do not have an incentive to SUD counseling over other, better paid, counseling credentials:
"Why would you use your education to study addiction treatment to become a certified addiction counselor who works for minimum wage when you can work for $75 per hour as a marriage and family therapist?... We are losing the best and the brightest--when they do get their master's degree they license with one of the licensing boards in CA and then leave the field because they can make more money elsewhere. It pays so poorly, and it [addiction counseling license] is not recognized by the state". Students are not choosing it and schools are not teaching to it because there is no license track at the end of the career ladder."
State licensure appears to be the key missing component in efforts to fully professionalize the SUD field and to incentivize professionals to qualify for SUD counseling credentials. Minimum skill requirements imposed by the state are likely to have a positive impact on salaries while at the same time defining and codifying a professional identity for practitioners in this field comparable to other counseling professions
Impact of System Transformation on Substance Use Disorder Professionals
The DMC-ODS currently being piloted is transforming the SUD landscape with implications for workforce development. The barriers discussed in the previous section are all addressed by the DMC-ODS to varying degrees.
System Integration and "Culture Change"
As mentioned previously, California's integration of SUD treatment services with mental and physical health predates the approval of the DMC-ODS waiver in 2015. Under the waiver, however, these efforts have gained additional institutional supports. One of the stated goals of the DMC-ODS is to facilitate coordination between SUD providers and the rest of the health care system. For example, one of the requirements for inclusion in the DMC-ODS is for the county to enter into a memorandum of understanding with all Medi-Cal managed care plans that enroll beneficiaries served by the DMC-ODS in the county, to establish, at a minimum, mutual referral protocols, coordinated case management, and medical information sharing. This requirement has helped move the state in the right direction in terms of integration: A survey of county administrators conducted before the implementation of the DMC-ODS and repeated 1 year after implementation found that the opt-in counties experienced increased communication across departments of their health care systems, whereas non-ODS counties reported no similar improvements. Notably, all of the opt-in counties reported improved communication between SUD and mental health services and 86% reported communication improvements between SUD and physical health services.
These integration efforts are contributing to the "mainstreaming" of SUD treatment as part of the overall health care landscape; this goes a long way toward strengthening the professional identity of practitioners as health care providers
Incentives for SUD Workforce Development
County systems participating in the waiver are required to comply with Medicaid Managed Care Regulations (42 CFR Part 438), including requirements related to network adequacy and quality reporting. This, in conjunction with the expansion of covered services, has provided incentives for counties to develop the size and skill levels of their SUD workforce by increasing the number of provider organizations in their networks and by enhancing staff adequacy provisions in their provider contracts. In the long run, these developments are expected to benefit the SUD workforce. They do, however, pose some immediate challenges that are discussed in further detail in the section, "Remaining Challenges and Future Directions."
Increases in Reimbursement Rates
The ability of ODS counties to set their own reimbursement rates for SUD services is arguably the single most important workforce development facilitator. In addition to the ability to take local conditions into consideration in rate setting, the waiver gives counties the authority to establish rate parity between mental health and SUD services. While acknowledging this as a promising development in the long run, our informants stressed that SUD counselors will need qualifications comparable to mental health counselors in order to achieve comparable rates. That is, attracting qualified professionals into the SUD field is a prerequisite for this workforce to achieve full rate parity. We return to this point in the next section.
Development of a Peer Recovery Workforce
Peer recovery supports in non-ODS counties can only be billed through a certified facility; however, the state does not require peer recovery specialists to register with a certification board as a prerequisite for practice, and hence, they do not need to complete even the 9-hour training required by certification boards. In ODS counties, peers can bill as individuals for RSS (although not for other service modalities), and comparable to the mental health side, they can meet clients in the community, and in their home to provide wraparound supports. The DMC-ODS waiver includes a requirement to provide SUD peer supports as a component of recovery services funded through the waiver. Counties that choose to make use of this provision are required to submit an SUD Peer Support Training Plan to the California Department of Health Care Services (DHCS) for approval. At a minimum, the training plan should address:
Development of a comprehensive, individualized client plan that includes specific goals.
Person-centered approaches that actively engage and empower clients and/or their designated proxies.
A formally defined supervision protocol for peer recovery support workers.
A well-defined process to ensure that peer support staff complete training and receive a county SUD Peer Support designation.
A methodology for assuring that SUD peer support staff obtain a basic set of competencies necessary to perform and document the peer support function.
A method to evaluate the peer's ability to support recovery from SUDs.
In other words, the county opt-in proposals that include reimbursement for peer services are required to also describe the county's proposed plan for training and qualifying peer specialists for approval by the DHCS, since there are currently no state-level training and qualification standards for these newly reimbursable services.
The DHCS provides training and technical assistance to counties in developing their peer-to-peer recovery workforce in line with the above criteria. Administrators of ODS counties often participate in these sessions to share their accomplishments and challenges in this area.
In summary, the DMC-ODS waiver is promoting the development of core competencies, well-defined training programs, formal supervision protocols, and performance evaluation methods for peer recovery support workers in the state.
Training and Technical Assistance on System Transformation
The DMC-ODS constitutes a fundamental transformation of California's service delivery system for SUD treatment, introducing new regulatory, administrative, contracting, billing, assessment, service delivery, and performance reporting practices that county administrations and their provider networks need to adopt. This necessitates a comprehensive training and technical assistance infrastructure to support providers and administrators alike. To meet these needs, the California DHCS has contracted with the California Institute for Behavioral Health Solutions (CIBHS) to provide training to counties and providers in planning for, applying, and implementing the waiver.
The county training plan developed for this purpose covers the following areas:
Assessing the existing service system and the infrastructure development needed to integrate additional service modalities required by the waiver.
Developing a provider network in line with the waiver's standard terms and conditions:
Drafting quality assurance plans.
Overview of MAT.
Detailed review of each level of care covered by the waiver:
In addition to the above training areas, the CIBHS provides an online forum and blog and a resource library for counties and providers. Since each participating county has a different waiver implementation plan, they offer county-specific learning collaboratives and other training resources for providers and enrollees.
Remaining Challenges and Future Directions
Recruiting a qualified workforce to meet the terms and conditions of the DMC-ODS remains one of the leading challenges for counties. Although the waiver has contributed to redefining the SUD field as a professional health care specialty with its own core competencies and career ladder, this "culture change" is still in its early stages. Some counties that attempt to impose new training and practice hour requirements meet with resistance from their existing workforce. For example, when the Division of Substance Abuse Prevention and Control in Los Angeles County tried to impose 90 hours of specialized course work and 3 months of supervised practice in addition to the basic 9-hour orientation for SUD counselors as a requirement for joining the county's provider network, provider organizations found it difficult to recruit qualified staff and existing staff found the new requirements too burdensome. Our informant from the county described these tensions as follows:
"We are in kind of a back and forth with providers about whether or not it's desirable for the county to have requirements above and beyond those of the state. Per the state, you can bill for all of these services as a registered counselor [with a 9-hour training], but we're trying to add some additional quality controls to that and some of our providers feel that we shouldn't be doing that."
In Los Angeles County, these tensions have resulted in some provider organizations discontinuing their contracts and some practitioners leaving the county. Although the Deputy Director of California County Behavioral Health Directors Association informed us that this type of "provider walkout" is not an overarching issue across all opt-in counties, it is still an important lesson learned about one of the "growing pains" of system transformation.
The need for state-level legislation that defines the field and regulates licensing and certification for different levels of SUD practice was mentioned by all of our informants as an important gap in professionalizing the field and attracting qualified practitioners; informants added that this legislative effort needs to be accompanied by state-level workforce development efforts that provide training, education, and incentives to attract qualified new practitioners to replace retiring practitioners.
Assembly Bill 2804 introduced during the last legislative session included provisions that addressed these barriers. The bill included provisions that the DHCS:
Conduct a quality assessment of addiction treatment, prevention, and integrated workforces that includes a sunrise review of addiction counselors.
Require that approved certifying organizations formalize a career ladder for addiction professionals that encompasses registrants through master's level counselors.
Adopt standards for peer specialists and intervention specialists so that those specialists can be included in regulations for certifying organizations.
The bill also included funding for SUD training and incentives such as fee waivers and student loan forgiveness. All of our informants mentioned this legislative effort as an important step forward. The Assembly decided to send AB 2804 to its Health Committee but failed to advance any further before the end of the session. SUD workforce advocates are continuing their efforts on several fronts. An SUD licensure bill is in preparation for submission to the legislature in January 2019. Additionally, CCAPP has submitted a budget request for 1.5 million dollars to be added to the state's Health Workforce Education and Training budget for some of the SUD workforce development efforts that were part of the moribund AB 2804. The request indicates that,
"[t]he funding would help the [SUD] profession in the following ways:
Educational stipends for students and registered SUD counselors seeking certification
Development of a statewide SUD workforce needs assessment report
Development of a quality assessment for addiction treatment, prevention, and integrated workforces that includes a sunrise review for addiction counselors
Development of a Medication Assisted Treatment (MAT) Training to educate the SUD workforce about patient-centered MAT treatment modalities
Development of an LGBTQI+ Treatment Quality Assessment tool and trainings to allow providers to assess the quality of treatment they are providing to the LGBTQI+ community and to identify goals for improvement"
CCAPP has already initiated a sunrise review for addiction counselors.
State officials are currently working on the 2020 renewal of the waiver with the goal of further institutionalizing DMC-ODS and expanding coverage to ASAM levels 3.7 and 4.0, which are not covered under the current waiver. Informants indicated that lessons learned from the initial years are guiding this work, which they view as further cause for optimism
As the nation's trailblazer in developing an organized SUD service delivery system, California offers many lessons learned--both through its accomplishments and the challenges encountered by some of its counties. One important lesson that can be derived from this experience is that the success of a comprehensive service system with quality controls and performance monitoring is highly dependent on the preexisting practice landscape and "culture," and relatedly, on the availability of a regulated and skilled professional workforce. Increasing the demand for a skilled workforce and establishing service quality requirements is likely to pose challenges and tensions if there are workforce shortages and few incentives to attract new entries into the field. Legislative efforts currently under way will go a long way toward responding to these challenges as the DMC-ODS demonstration expands and eventually becomes institutionalized statewide.